Electrophysiological Responses in the Human S3 Nerve During Sacral Neuromodulation for Fecal Incontinence

Abstract

Intra-operative electrode placement for sacral neuromodulation (SNM) relies on visual observation of motor contractions alone, lacking complete information on neural activation from stimulation. This study aimed to determine whether electrophysiological responses can be recorded directly from the S3 sacral nerve during therapeutic SNM in patients with fecal incontinence, and to characterize such responses in order to better understand the mechanism of action (MOA) and whether stimulation is subject to changes in posture. Eleven patients undergoing SNM were prospectively recruited. A bespoke stimulating and recording system was connected (both intraoperatively and postoperatively) to externalized SNM leads, and electrophysiological responses to monopolar current sweeps on each electrode were recorded and analyzed. The nature and thresholds of muscle contractions (intraoperatively) and patient-reported stimulation perception were recorded. We identified both neural responses (evoked compound action potentials) as well as myoelectric responses (far-field potentials from muscle activation). We identified large myelinated fibers (conduction velocity: 36–60 m/s) in 5/11 patients, correlating with patient-reported stimulation perception, and smaller myelinated fibers (conduction velocity <15 m/s) in 4/11 patients (not associated with any sensation). Myoelectric responses (observed in 7/11 patients) were attributed to pelvic floor and/or anal sphincter contraction. Responses varied with changes in posture. We present the first direct electrophysiological responses recorded from the S3 nerve during ongoing SNM in humans, showing both neural and myoelectric responses. These recordings highlight heterogeneity of neural and myoelectric responses (relevant to understanding MOA of SNM) and confirm that electrode lead position can change with posture.

Measures of Dosage for Spinal-Cord Electrical Stimulation: Review and Proposal

“…Miller et al [16] considered charge per second (average current) as a definition of dose for 10 kHz, burst and tonic stimulation. This is an excellent measure for comparing total power requirements and partially accounts for the change of threshold with frequency as described by Gmel [17]; however it is possible to construct an example that demonstrates shortcomings of this method for stimulation frequencies below 100 Hz. If we consult Table 3 from Abejón and colleagues [18], we can see that at 40 Hz and 300 µs pulse duration, the therapy threshold is 8.17 mA and thus the charge per second under those conditions is 40 × 300e −6 × 0.00817 = 98 µA.…”

“…These observations suggest that ECAP amplitude is a relevant measure of dose for epidemiological studies but specific values relevant to one patient may not be appropriate for another, or even for another electrode within the same patient. [17] As a definition of dose, ECAP is not reliably transferable.…”